Vasectomy reversal vs. sperm retrieval with in vitro fertilization: a contemporary, comparative analysis

[Desire to have children after vasectomy : Vasectomy reversal or assisted reproductive technology?]

The vasectomy is a safe and effective method of contraception for men. Up to 6% of men who underwent vasectomy have a renewed child wish. Microsurgical vasectomy reversal (VR) in men, microsurgical epididymal sperm aspiration (MESA), or testicular sperm extraction (TESE) in men plus assisted reproductive technology (ART) in the female partner as well as the combination of VR and MESA/TESE plus ART represent established therapeutic strategies. Various factors may impact the success of VR, as defined by patency and pregnancy rate following VR, including the female partner's age, the obstructive interval, and the surgical VR technique. There is no difference in the pregnancy and live birth rate following VR or MESA/TESE plus ART. However, following MESA/TESE plus ART, time to pregnancy is shorter compared with VR. Overall, VR is more cost-effective than MESA/TESE plus ART and allows for a lower therapeutic burden, especially in the female partner. In addition, VR combined with TESE plus-if necessary-ART is more cost-effective than MESA/TESE plus ART alone, even in female partners with advanced age. For successful counseling regarding the different therapy options for a renewed child wish after vasectomy, it is important to evaluate the underlying individual situation of the couple.

Cost Removed! Do Different Factors Influence Motivation for Vasectomy Reversal When Cost Is Not an Issue?

INTRODUCTION

Vasectomy is a relatively common procedure performed for the purposes of sterilization; however, up to 6% of men that undergo vasectomy wish for its reversal at some point. Few studies have examined the motivation behind vasectomy reversal (VR), especially within special populations, such as the U.S. Military. The aim of this study was to examine the motivations of U.S. Military service members (SMs) who opted for VR surgery, considering their unique access to free health care.

MATERIALS AND METHODS

We conducted a retrospective record review of microsurgical VRs performed by a single surgeon (DJH) between January 2020 and May 2023. We evaluated patient's age at which vasectomy was performed, age at VR, reasons for seeking VR surgical care, number of children fathered before the vasectomy, and the age of the current partner.

RESULTS

A total of 106 patients underwent VR during the study period, and 102 of them had their medical records available for review. The average age at the time of vasectomy was 31.3 years, while the average age at VR was 40.2 years. The average spousal age at the time of seeking VR was 34.8 years. Before undergoing vasectomy, the men had fathered an average of 2.7 children. Most men were enlisted members of the military (68) and of all service branches, Army represented the greatest number (50). The vast majority of men (76) cited having a new partner after divorce as the primary motivation for seeking VR. Within this group, 57 were remarried, 15 were in a new relationship, 3 were newly engaged, and 1 desired fertility for future relationships. Additionally, 21 sought VR to have more children with the same spouse. Among them, motivating factors included changes to financial status and improvement in partner's health condition. A minority of patients (2) desired VR due to post vasectomy pain syndrome or religious beliefs.

CONCLUSIONS

Our study demonstrates that the primary driver for seeking VR surgical care among SMs was the desire for fertility with a new partner, which correlates with trends in the civilian sector. Approximately 20% of the men cited the wish to have more children with the same partner as their motivation. Non-fertility reasons, such as religious beliefs and post vasectomy pain syndrome, were also observed, albeit less frequently.

Anti-sperm Antibodies as an Increasing Threat to Male Fertility: Immunological Insights, Diagnostic and Therapeutic Strategies

It is a fact that sperm possess antigenic properties. Substantial scientific research suggests that specific antibodies that attach to sperm antigens can induce infertility in both humans and other species. Antisperm antibodies (ASA) represent a significant etiology of infertility in humans, leading to immunoinfertility. The association between ASA and infertility is multifaceted. The observation of sperm agglutination, although not conclusive for the diagnosis of immunological infertility, may suggest the presence of ASA. Nevertheless, ASA may also manifest in the lack of any sperm agglutination. Managing ASA from an andrological perspective depends on the underlying cause and the specific approaches healthcare professionals adopt. The precise etiology of male infertility resulting from ASA remains unclear. Current research has examined the impact of ASA and its prevalence among infertile males to understand the relationship between ASA and changes in semen parameters. However, the findings have been inconclusive. Numerous techniques have been documented for the management of immunoinfertility. This review examines the importance of ASA in the context of infertility, encompassing the postulated mechanisms underlying the development of ASA, the various assays employed for detecting them, and the available treatments.

Effects of antisperm antibodies post vasectomy reversal on pregnancy rates

OBJECTIVE

To investigate the correlation between antisperm antibodies (ASAs), pregnancy rates, and the method of conception following vasectomy reversal. This is particularly relevant as patients undergoing vasectomy reversal often express concerns about the potential inhibitory effects of ASAs on achieving pregnancy. Additionally, the American Urological Association guidelines for vasectomy emphasize the need for further research to address this question.

PATIENT AND METHODS

We conducted a retrospective analysis involving chart reviews and phone interviews with individuals who underwent vasectomy reversal at our institution between May 2015 and April 2023. Patients who underwent vasectomy reversal for reasons other than fertility, as well as those lacking postoperative semen analysis with ASA data, were excluded. We classified patients based on low (below 50%) or high (50% or above) ASA levels determined by their initial postoperative semen analysis. The primary outcome measured was the pregnancy rate, including details on the method of conception.

RESULTS

A total of 145 patients were subjected to chart review. The median age at the time of surgery was 43 years, with a median obstruction interval of 7.7 years. The median age of their partners was 29 years. The majority (80%) of patients underwent bilateral vasovasostomy. Among them, 60 patients (41.4%) exhibited low (< 50%) ASA levels, while 85 (58.6%) had high (≥ 50%) ASA levels. Follow-up phone interviews were completed by 48 patients. Among them, the 19 men with low ASA levels, 13 (68.4%) achieved pregnancy, with 6 (31.6%) experiencing spontaneous conception. For the 29 men with high ASA levels, 21 (72.4%) achieved pregnancy, including 11 (38%) through spontaneous conception. The p-value from Fisher's exact test was 0.2.

CONCLUSIONS

Our findings suggest that ASA levels do not show a significant association with either the pregnancy rate or the method of conception following vasectomy reversal.

Antisperm Antibody Levels After Vasectomy Reversal Are Not Associated With Pregnancy Rates or Method of Conception

OBJECTIVE

To examine the relationship between antisperm antibody (ASA), pregnancy rates, and method of conception following vasectomy reversal, given that before and after vasectomy reversal, patients wonder if ASAs will prevent them from achieving pregnancy and American Urological Association vasectomy guidelines call for additional research to answer this question.

METHODS

We performed retrospective chart review and phone interview of patients who underwent vasectomy reversal at our institution from 1/1/2000 to 12/31/2018. We excluded patients who underwent vasectomy reversal for pain, or without postoperative semen analysis with ASA. We categorized patients as having low (<50%) or high (≥50%) ASA levels using the first postoperative semen analysis. Our primary outcome was pregnancy rate, including method of conception. Differences in pregnancy rates were tested using Fisher exact test.

RESULTS

Two hundred and four patients were chart reviewed. Median age at time of surgery was 40years and median obstruction interval was 7.3years. Median partner age was 32years. One hundred sixty-four (80%) patients underwent bilateral vasovasostomy. Eighty-five patients (42%) had low (<50%) ASA levels and 119 (58%) had high (≥50%) ASA levels. Sixty-seven patients completed phone interviews. Of 27 men with low ASA levels, 19 (70%) achieved a pregnancy with 16 (59%) spontaneous pregnancy. Of 40 men with high ASA levels, 30 (75%) achieved a pregnancy with 16 (40%) spontaneous pregnancy. The Fisher exact test P-value was .2.

CONCLUSION

ASA levels are not associated with pregnancy rate or method of conception after vasectomy reversal. These findings can improve patient counseling before and after vasectomy reversal.

From Diagnosis to Treatment: Comprehensive Care by Reproductive Urologists in Assisted Reproductive Technology

Infertility is a global health concern, with male factors playing an especially large role. Unfortunately, however, the contributions made by reproductive urologists in managing male infertility under assisted reproductive technology (ART) often go undervalued. This narrative review highlights the important role played by reproductive urologists in diagnosing and treating male infertility as well as any barriers they face when providing services. This manuscript presents a comprehensive review of reproductive urologists' role in managing male infertility, outlining their expertise in diagnosing and managing male infertility as well as reversible causes and performing surgical techniques such as sperm retrieval. This manuscript investigates the barriers limiting urologist involvement such as limited availability, awareness among healthcare professionals, and financial constraints. This study highlights a decrease in male fertility due to lifestyle factors like sedentary behavior, obesity, and substance abuse. It stresses the significance of conducting an evaluation process involving both male and female partners to identify any underlying factors contributing to infertility and to identify patients who do not require any interventions beyond ART. We conclude that engaging urologists more effectively in infertility management is key to optimizing fertility outcomes among couples undergoing assisted reproductive technology treatments and requires greater education among healthcare providers regarding the role urologists and lifestyle factors that could have an effect on male fertility.

Sperm immotility is associated with epididymis metabolism disorder in mice under obstructive azoospermia

Obstructive azoospermia (OA) accounts for approximately 40% of males who suffer from azoospermia of male infertility. Currently, available treatment for OA consists of reproductive tract surgical reconstruction and sperm retrieval from the testis. However, both treatments result in low fertility compared to normal pregnancy, and the main reason remains largely unknown. Previous studies have shown that the quality of sperm retrieved from OA patients is poor compared with normal adult males but without an in-depth study. Herein, we generated a mouse OA model with vasectomy to evaluate sperm quality systematically. Our results showed that the testis had normal spermatogenesis but increased apoptotic activity in both OA patients and mice. More importantly, epididymal morphology was abnormal, with swollen epididymal tubules and vacuole-like principal cells. Especially, sperm retrieved from the epididymis of OA mice showed poor motility and low fertilization ability in vitro. Using mass spectrometry in epididymal fluid, we found differences in the expression of key proteins for sperm maturation, such as Angiotensinogen (AGT), rhophilin-associated tail protein 1 (ROPN1), NPC intracellular cholesterol transporter 2 (NPC2), and prominin 1 (PROM1). Furthermore, our results demonstrated that AGT, secreted by epididymal principal cells, could regulate sperm motility by managing PKCα expression to modify sperm phosphorylation. In conclusion, our data evaluate sperm quality systematically in OA mice and contribute to the understanding between the sperm and epididymis, which may provide novel insight into treating male infertility.

The pregnancy outcomes in patients with epididymal obstructive azoospermia after microsurgical vasoepididymostomy: a systematic review and meta-analysis

Purpose

Pregnancy outcomes (overall patency rate, overall pregnancy rate, natural pregnancy rate, and the ratio of patients with pregnancy by assisted reproductive technology) after microsurgical vasoepididymostomy (MVE) in patients with epididymal obstructive azoospermia (EOA) were assessed through meta-analysis.

Method

We searched PubMed, Embase, Web of Science, and the Cochrane Library databases up to 28 September 2022 for published literature related to retrospective or prospective clinical studies of obstructive azoospermia after apparent microsurgical vasoepididymostomy. Our search terms included obstructive azoospermia, epididymis obstruction, epididymal obstruction and vasoepididymostomy, and epididymovasostomy. Two researchers independently performed the literature search and assessed the eligibility of selected studies according to established inclusion criteria. The meta-analysis was performed using RevMan 5.4 software.

Result

A total of 504 patients with EOA were included in 10 studies (including 2 prospective clinical studies and 8 retrospective clinical studies). The mean patency rate after MVE was 72% (95% CI 68-76%). The overall pregnancy rate was 34% (95% CI 30-38%). The natural pregnancy rate is 21% (95% CI 17-24%). The ratio of patients with pregnancy by assisted reproductive technology (ART) was 34.9%. For the factors affecting pregnancy outcomes after MVE, the overall pregnancy rates in patients receiving bilateral MVE were significantly higher than those receiving unilateral MVE (75.4 vs. 24.6%). The mean best sperm count and sperm motility in patients with overall pregnancy were significantly higher than those with failing pregnancies. For the subgroup meta-analysis of microsurgical vasoepididymostomy, there were no statistically significant differences in the overall patency rate (68 vs. 70%), the overall pregnancy rate (33 vs. 37%), the natural pregnancy rate (20 vs. 23%), the ratio of ART (30 vs. 28%) in end-to-side or end-to-end anastomosis, and longitudinal or triangular intussusception MVE.

Conclusion

Vasectomy patency rates are higher, but natural pregnancy rates are lower in EOA male infertility patients after MVE. Altering the MVE procedures alone does not significantly improve pregnancy outcomes, but ART after MVE could improve the chance of pregnancy regardless of sperm parameters. We recommended that human sperms from EOA male infertility patients should be cryopreserved during intraoperative MVE for application in the subsequent ICSI treatment procedure.

Vasectomy Regret or Lack Thereof

Background

Vasectomy is a procedure that results in permanent yet reversible sterility and remains a great contraceptive option for many. Previous research studies have highlighted frequency of vasectomy utilization, defining characteristics of individuals who opt for this method, various surgical techniques, and the risks and benefits associated with the procedure. What remains to be defined is why or why not individuals may experience post-vasectomy regret and whether the previous characteristics correlate.

Objective

The objective of this review is to synthesize information regarding reasons individuals may regret their vasectomy and seek reversal, what options exist for accomplishing the reversal, and patients' fertility prognosis post-vasovasostomy.

Methods

This review utilized a combination of secondary and tertiary data analysis across a wide scope of academic databases pertaining to the topic of interest.

Results

Typically, most males who have sought a vasectomy are satisfied with their decision, however, approximately 6% of this population seeks reversal. Key factors influencing vasectomy regret include age at the time of vasectomy, parental status, pre- and post-operative relationship status, unresolved physical and psychosexual problems, and development of chronic scrotal pain following the procedure. Few options exist for vasectomy reversal including microsurgical reconstructive vasectomy reversal (VR) and sperm extraction for in vitro fertilization. There is no guarantee that fertility will be restored in any case but a major predictive factor for success is the time interval prior to reversal.

Conclusion

Vasectomy is intended to be a permanent form of contraception; however, a minor chance remains that individuals may experience post-operative regret due to various factors. This warrants proper comprehensive counseling by the patient's provider regarding benefits and risks, procedural outcomes, opportunities for reversal, and fertility prognosis.

Microsurgical Management of Male Infertility: Compelling Evidence That Collaboration with Qualified Male Reproductive Urologists Enhances Assisted Reproductive Technology (ART) Outcomes

A male factor plays a significant role in a couple's reproductive success. Today, advances in reproductive technology, such as intracytoplasmic sperm injection (ICSI), have allowed it to be possible for just a single sperm to fertilize an egg, thus, overcoming many of the traditional barriers to male fertility, such as a low sperm count, impaired motility, and abnormal morphology. Given these advances in reproductive technology, it has been questioned whether a reproductive urologist is needed for the evaluation and treatment of infertile and subfertile men. In this review, we aim to provide compelling evidence that collaboration between reproductive endocrinologists and reproductive urologists is essential for optimizing a couple's fertility outcomes, as well as for improving the health of infertile men and providing cost-effective care.